Hidatidosis pancreática en una niña de 5 años / Pancreatic echinococcosis in a 5-year-old girl

La hidatidosis pancreática representa el 0,2-0,6 % de los casos, siendo la población pediátrica la de mayor riesgo. Las lesiones suelen localizarse en cabeza del páncreas (50-58 %); la localización en cuerpo y cola del páncreas se encuentra en el 24-34 % y el 19 %, respectivamente. Dada la posibilidad de complicaciones, suele realizarse tratamiento quirúrgico. Se sugiriere indicar albendazol antes y después del acto quirúrgico por los riesgos de ruptura y diseminación de los protoescólices. Se presenta el caso de una niña de 5 años de edad con dolor abdominal progresivo y lesión quística en páncreas compatible con hidatidosis en la ultrasonografía. En la tomografía computada se observa compresión de la vía biliar. La hemoaglutinación indirecta fue negativa. Presentó elevación de la bilirrubina total, con franco predominio de bilirrubina directa, y aumento de enzimas hepáticas. Se realizó laparotomía exploradora, colecistectomía y destechamiento del quiste. Evolucionó favorablemente, continuó con albendazol durante 3 meses luego de la cirugía.

Pancreatic echinococcosis accounts for 0.2­0.6% of cases, with the pediatric population being at a higher risk. Most commonly, pancreatic lesions occur in the head of the pancreas (50­58%); and in the body and tail in 24­34% and 19% of cases, respectively. Given the potential complications, surgery is usually performed. Albendazole is recommended before and after the surgery due to the risks for rupture and dissemination of protoscolices. Here we describe the case of a 5-year-old girl with progressive abdominal pain and cystic lesion in the pancreas compatible with echinococcosis in the ultrasound. The computed tomography showed bile duct compression. Indirect hemagglutination was negative. She had elevated total bilirubin, with a clear predominance of direct bilirubin, and high liver enzymes. Exploratory laparotomy, cholecystectomy, and unroofing of the cyst were performed. The patient had a favorable course and continued with albendazole for 3 months after the surgery.

Annular pancreas in neonate patients Vomiting and weight loss in a 13-day newborn / Pâncreas Anular no período neonatal Vômitos e perda de peso em neonato com 13 dias de vida

Objective: Reinforce that, despite being a rare condition, the annular pancreas must be considered a differential diagnosis for intestinal obstructions in the newborn period. Case description: This case report refers to a 13-days newborn admitted to the emergency room presenting with postprandial vomiting and progressive weight loss since maternity discharge. The patient did not respond to initial interventions that included IV antibiotics and nasogastric tube insertion. A contrast study of the upper digestive tract (esophagus, stomach, and duodenum) found a luminal narrowing on the second duodenal portion. The patient was submitted to an exploratory laparotomy which found a pancreatic-tissue ring involving the second part of the duodenum. Despite rare, we reinforce that the annular pancreas must be considered a differential diagnosis for intestinal obstructions in the newborn period. Comments: Annular pancreas is a rare congenital defect in which a ring of pancreatic tissue encircles the duodenum, causing different degrees of intestinal obstruction. (AU)

Objetivo: Evidenciar que, apesar de condição rara, o pâncreas anular deve se firmar como diagnóstico dife-rencial das obstruções intestinais no período neonatal. Descrição do caso: Este relato aborda o caso de uma paciente de 13 dias de vida admitida no pronto atendimento com queixa de volumosos vômitos pós-prandiais e perda de peso progressiva desde a alta da maternidade. Apesar das medidas iniciais, com ressuscitação volêmica, antibioticoterapia e passagem de sonda nasogástrica para descompressão, a paciente evolui sem melhora. Exame contrastado de esôfago-estômago-duodeno detectou estreitamento luminal da segunda porção duodenal. Paciente submetida à laparotomia exploradora, que evidenciou anel de tecido pancreático estreitando o trânsito intestinal na região. Comentários: O pâncreas anular é uma anomalia congênita rara na qual um anel de tecido pancreático envolve a porção descendente do duodeno, causando graus variados de obstrução intestinal extrínseca. (AU)

Ascitis pancreática traumática, manejo conservador: reporte de un caso / Post-traumatic pancreatic ascites, conservative management: a case

Resumen Objetivo: Presentar el caso de un paciente masculino adulto joven, con ascitis pancreática secundaria a lesión del conducto pancreático por trauma abdominal cerrado, tratado con éxito con terapia conservadora. Materiales y Método: Datos e imágenes recopilados de la historia clínica del Hospital Universitario de Santander, previo consentimiento informado. Resultados: Sexo masculino de 21 años con antecedente de trauma abdominal cerrado, quien consulta por distensión, dolor abdominal progresivo y pérdida de peso no cuantificada. Ante sospecha de lesión de conducto pancreático se solicitó pancreatografía por resonancia magnética que evidencia una alteración del segmento proximal del conducto pancreático principal asociado a lesión quística en el borde anterior de la unión de la cabeza con el cuerpo pancreático. Se decidió manejo conservador por 4 semanas con colocación de dren abdominal, reposo intestinal, asociado a nutrición parenteral total y análogos de somatostatina. Discusión: Un 5% del trauma abdominal cerrado puede provocar pancreatitis y fugas en el conducto pancreático. Conclusión: La lesión del conducto pancreático principal debe sospecharse en todos los pacientes con trauma abdominal cerrado. El manejo debe realizarse con una planificación cuidadosa y exhaustiva.

Aim: To present the case of a young adult male patient, with pancreatic ascites secondary to pancreatic duct injury due to blunt abdominal trauma, treated successfully with conservative therapy. Materials and Method: Data and images were obtained from the clinical chart of the "Hospital Universitario de Santander" with prior informed consent. Results: 21-year-old male patient with a blunt abdominal trauma background, who consulted for distension, progressive abdominal pain, and subjective weight loss. Due to suspicion of a pancreatic duct injury, a magnetic resonance cholangiopancreatography was requested, which showed an alteration of the proximal segment of the main pancreatic duct associated with a cystic lesion at the anterior border of the junction between the pancreatic head and body. Treatment consisted of a 4-week conservative therapy with the placement of an abdominal drain, bowel rest, associated with total parenteral nutrition and somatostatin analogs. Discussion: A 5% of blunt abdominal trauma can cause pancreatitis and pancreatic duct leaks. Conclusión: Pancreatic duct injury should be suspected in every patient with blunt abdominal trauma. Management must be done with careful and thorough planning.

Páncreas divisum y pancreatitis: su importancia en la práctica cotidiana / Pancreas divisum and pancreatitis: its importance in everyday practice

Pancreas divisum (PD) is the most common congenital anatomical variant of the pancreas. Its etiological implication in recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) has been recurrently questioned. Normal anatomy and variants: 80-90% of the population has normal anatomy, with excretion of exocrine pancreatic secretion to the duodenum by the major papilla. Three anatomical variants of PD have been described: classic PD with visible ventral duct, but total absence of fusion; PD with absence of ventral duct; and incomplete PD, with a rudimentary connection between the ventral and dorsal ducts. Clinical implication: This anatomical variant is symptomatic in less than 5% of the carriers, being associated to higher prevalence in patients with RAP However, the relationship between PD and RAP is considered probable, only in cases of association with mutation of the CFTR gene. Obstructive CP can develop in the segment drained by the dorsal duct. Diagnosis: Magnetic resonance cholangiopancreatography (MRCP) is the most sensitive diagnostic method. Other non-invasive diagnostic methods are endosonography and computed tomography (CT), the latter with lower performance. Treatment: The current trend in acute pancreatitis (AP) where PD is assumed as an etiological factor, is endoscopic resolution, with papillotomy with or without a pancreatic stent.

El páncreas divisum (PD) es la variante anatómica congénita más frecuente del páncreas. Su implicancia etiológica en pancreatitis aguda recurrente (PAR) y pancreatitis crónica (PC) ha sido frecuentemente cuestionada. Anatomía normal y variantes: 80-90% de la población presenta anatomía normal, con salida de secreción pancreática exocrina al duodeno por la papila mayor. Se han descrito 3 variantes anatómicas: PD clásico con conducto ventral visible, pero ausencia total de fusión; PD con ausencia de conducto ventral; y PD incompleto, con conexión rudimentaria entre los conductos ventral y dorsal. Implicancia clínica: Esta variante anatómica da síntomas en menos de 5% de los portadores, asociándose a mayor prevalencia en pacientes con PAR. Sin embargo, se considera probable la relación entre PD y PAR, solo en casos de asociación con mutación del gen CFTR. Pancreatitis crónica (PC) obstructiva se puede desarrollar en el segmento drenado por el conducto dorsal. Diagnóstico: La colangiopancreatografía por resonancia magnética (CPRM) es el método diagnóstico más sensible. Otros métodos diagnósticos no invasivos son la endosonografía y tomografía computada (TC), este último de menor rendimiento. Tratamiento: La tendencia actual en PA donde se asume PD como factor etiológico, es la resolución endoscópica, con papilotomía con o sin stent.

Intrapancreatic accessory spleen / Baço acessório intrapancreático

ABSTRACT An asymptomatic 79-year-old woman, with incidental finding on abdominal ultrasound of a solid nodule in the tail of the pancreas. Magnetic resonance imaging showed a 12mm solid tumor. The suggested diagnosis was pancreatic neuroendocrine tumor. The pathological examination showed an intrapancreatic splenic tissue. This is a rare ectopic location of spleen tissue and it should be considered in the differential diagnosis of pancreatic solid tumors.

RESUMO Mulher de 79 anos, com achado incidental em ultrassonografia de abdome de lesão sólida em cauda de pâncreas. Em ressonância magnética, foi confirmada lesão de 12mm. Foi aventada a hipótese diagnóstica de tumor neuroendócrino não secretor, sendo realizada pancreatectomia distal laparoscópica. Em estudo anatomopatológico, diagnosticou-se tecido esplênico, configurando baço acessório intrapancreático. Este tipo de manifestação topográfica de baço é rara, mas deve fazer parte dos diagnósticos diferenciais em tumores sólidos do pâncreas.

T2-Weighted Liver MRI Using the MultiVane Technique at 3T: Comparison with Conventional T2-Weighted MRI

OBJECTIVE: To assess the value of applying MultiVane to liver T2-weighted imaging (T2WI) compared with conventional T2WIs with emphasis on detection of focal liver lesions. MATERIALS AND METHODS: Seventy-eight patients (43 men and 35 women) with 86 hepatic lesions and 20 pancreatico-biliary diseases underwent MRI including T2WIs acquired using breath-hold (BH), respiratory-triggered (RT), and MultiVane technique at 3T. Two reviewers evaluated each T2WI with respect to artefacts, organ sharpness, and conspicuity of intrahepatic vessels, hilar duct, and main lesion using five-point scales, and made pairwise comparisons between T2WI sequences for these categories. Diagnostic accuracy (Az) and sensitivity for hepatic lesion detection were evaluated using alternative free-response receiver operating characteristic analysis. RESULTS: MultiVane T2WI was significantly better than BH-T2WI or RT-T2WI for organ sharpness and conspicuity of intrahepatic vessels and main lesion in both separate reviews and pairwise comparisons (p < 0.001). With regard to motion artefacts, MultiVane T2WI or BH-T2WI was better than RT-T2WI (p < 0.001). Conspicuity of hilar duct was better with BH-T2WI than with MultiVane T2WI (p = 0.030) or RT-T2WI (p < 0.001). For detection of 86 hepatic lesions, sensitivity (mean, 97.7%) of MultiVane T2WI was significantly higher than that of BH-T2WI (mean, 89.5%) (p = 0.008) or RT-T2WI (mean, 84.9%) (p = 0.001). CONCLUSION: Applying the MultiVane technique to T2WI of the liver is a promising approach to improving image quality that results in increased detection of focal liver lesions compared with conventional T2WI.

Pyogenic Pancreatic Abscess Mimicking Pancreatic Neoplasm: A Four-Case Series / 대한소화기학회지

A pyogenic pancreatic abscess mimicking pancreatic neoplasm in the absence of acute pancreatitis is rare. We report four patients who each presented with a pancreatic mass at the pancreas head or body without acute pancreatitis. The presenting symptoms were abdominal pain, fever, or weight loss. Abdominal CT scans showed low-density round masses at the pancreas head or body with/without lymphadenopathy. In each case, a PET-CT scan showed a mass with a high SUV, indicating possible malignancy. Comorbid diseases were identified in all patients: chronic pancreatitis and thrombus at the portal vein, penetrating duodenal ulcer, distal common bile duct stenosis, and diabetes mellitus. Diagnoses were performed by laparoscopic biopsy in two patients and via EUS fine needle aspiration in one patient. One patient revealed a multifocal microabscess at the pancreatic head caused by a deep-penetrating duodenal ulcer. He was treated with antibiotics and a proton-pump inhibitor. The clinical symptoms and pancreatic images of all the patients were improved using conservative management. Infective causes should be considered for a pancreatic mass mimicking malignancy.

The Expanding Role of Contrast-Enhanced Endoscopic Ultrasound in Pancreatobiliary Disease

Since its introduction into clinical practice in the 1980s, endoscopic ultrasound (EUS) has been described as a good imaging modality for the diagnosis of pancreatobiliary diseases. However, differential diagnosis of certain lesions based only on B-mode ultrasound images can be challenging. Clinical use of ultrasound contrast agents has expanded the utility of EUS from that of detection to characterization of pancreatobiliary lesions based on the enhancement features of contrast-enhanced EUS (CE-EUS). Current low mechanical index techniques for CE-EUS using second-generation contrast agents have a number of distinct advantages over conventional diagnostic modalities in evaluating pancreatobiliary lesions, including real-time assessment of perfusion pattern, availability, and the absence of exposure to radiation. This article describes the technical aspects of CE-EUS and reviews the expanding indications in pancreatobiliary diseases and further development of this technique.

Safety and Utility of Single-Session Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography for the Evaluation of Pancreatobiliary Diseases

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are essential for diagnosing and treating pancreatobiliary diseases. Single-session EUS and ERCP are considered to be essential in reducing the duration of hospital stays; however, complications are a primary concern. The aim of this study was to evaluate the safety and efficacy of single-session EUS and ERCP. Sixty-eight patients underwent single-session EUS and ERCP at a tertiary referral center between June 2008 and December 2012. We retrospectively reviewed patient data from a prospectively maintained EUS-ERCP database and evaluated the procedural characteristics and complications. Thirty-eight patients (56%) underwent diagnostic EUS, and 30 patients (44%) underwent EUS fine-needle aspiration, which had an overall accuracy of 100%. Sixty patients (89%) underwent therapeutic ERCP, whereas the remaining eight procedures were diagnostic. Thirteen patients underwent biliary stone extraction, and 48 underwent biliary drainage. The median total procedural time was 75 minutes. Complications were observed in seven patients (10%). Six complications were post-ERCP pancreatitis, which were resolved using conservative management. One patient developed Mallory-Weiss syndrome, which required endoscopic hemostasis. No sedation-related cardiopulmonary complications were observed. Single-session EUS and ERCP provided accurate diagnosis and effective management with a minimal complication rate.

Rendimiento diagnóstico del marcador tumoral CA 19-9 en la diferenciación entre patología bilio-pancreática benigna y maligna / Accuracy of the tumor marker CA 19-9 in the differentiation of benign and malignant bilio-pancreatic diseases

Introduction: CA 19-9 has been identified as a derivative of sialic Lewis blood group A and is expressed in 95 percent of the population. Several studies have documented an overproduction of CA 19-9 in malignant pancreatic and biliary tree diseases. The objective of this study is to determine the accuracy of the tumor marker CA 19-9 differentiating benign and malignant bilio-pancreatic diseases. Material and Methods: diagnostic test study. We reviewed the records of all patients with malignant bilio-pancreatic diseases and benign biliary calculous diseases evaluated in Hospital Base Osorno between august 2007 and december 2011, with CA 19-9 as part of their study. Results: 71 patients met the inclusion criteria, 17 men and 54 women, with a mean age of 60.7 +/- 15.3 years old. Twenty nine (40.8 percent) cases were benign and 42 (59.2 percent) cases malignant. For a cutoff level of 37 U/ml the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to differentiate benign from malignant disease was 81 percent, 72.4 percent, 81 percent and 72.4 percent, respectively. For a cut off level of 130 U/ml specificity and PPV increased to 96.6 percent and 96.4 percent, respectively. Conclusions: the use of CA 19-9 is useful in the diagnosis of patients with suspected bilio-pancreatic malignant disease. The optimization of the normal published value can help to improve accuracy.

Introducción: El CA 19-9 se ha identificado como un derivado siálico del grupo sanguíneo Lewis A y se expresa en el 95 por ciento de la población. Numerosos estudios han documentado una sobreproducción de CA 19-9 en tumores malignos del árbol biliar y páncreas. El objetivo de este estudio es determinar la utilidad del marcador tumoral CA 19-9 en la diferenciación de patología bilio-pancreática benigna y maligna. Material y Métodos: estudio de pruebas diagnósticas. Se revisaron los antecedentes de todos los pacientes con patología bilio-pancreática maligna y enfermedad litiásica biliar benigna, evaluados en el Hospital Base de Osorno entre agosto de 2007 y diciembre de 2011, a los que se les haya solicitado CA 19-9 como parte de su estudio. Resultados: 71 pacientes cumplieron los criterios de inclusión, 17 hombres y 54 mujeres, con una media de 60,7 +/- 15,3 años de edad. Veintinueve (40,8 por ciento) casos correspondieron patología benigna y 42 (59,2 por ciento) casos a patología maligna. Para un valor de corte de 37 U/ml la sensibilidad, especificidad, valor predictivo positivo (VPP) y valor predictivo negativo (VPN) para diferenciar enfermedad benigna de maligna fue de 81 por ciento, 72,4 por ciento, 81 por ciento y 72,4 por ciento, respectivamente. Para un valor de corte de 130 U/ ml la especificidad y el VPP aumentaron a 96,6 por ciento y 96,4 por ciento, respectivamente. Conclusiones: el uso del Ca 19-9 es útil en el proceso diagnóstico de pacientes con sospecha de patología bilio-pancreática maligna. La optimización de los valores sobre el valor de normalidad publicado puede ayudar a mejorar su rendimiento.

Primary pancreatic tuberculosis: a rare and elusive diagnosis

Primary pancreatic tuberculosis is an extremely rare entity, even in tuberculosis endemic areas. A 22-year-old male presented with features of obstructive jaundice. Ultrasonography and computed tomography scan showed mass in the pancreatic head for which he underwent a pancreatoduodenectomy. Histological examination of the specimen showed caseating granulomas. Antituberculous medicines were started and he remained well 18 months after surgery. Pancreatic tuberculosis is rare and is frequently confused with pancreatic cancer on clinical presentation as well as on imaging studies. A high index of suspicion is vital to avoid surgeries in this medically treatable, often misdiagnosed condition

Endoscopic ultrasound [EUS] as a diagnostic option for annular pancreas: a case report

Annular pancreas is a rare congenital condition of the pancreas where pancreatic tissue either partially or completely covers the duodenum by forming a ring. Endoscopic ultrasound is rarely considered as an initial diagnostic tool for annular pancreas. We here present the case of a 48-year-old male primarily provisionally diagnosed with a pancreatic mass for which a pancreatoduodenectomy was planned. However, an endoscopic ultrasound confirmed the diagnosis of annular pancreas.

Two Cases of Portal Annular Pancreas / 대한소화기학회지

Portal annular pancreas is one of the pancreatic fusion anomalies in which the uncinate process of the pancreas extends to fuse with the dorsal pancreas by encircling the portal vein or superior mesenteric vein. We report two consecutive patients with portal annular pancreas. The first case is a 71-year-old male patient who underwent a pancreaticoduodenectomy for intraductal papillary mucinous neoplasm in the head of pancreas. His preoperative computed tomography scan showed the suprasplenic type portal annular pancreas. The second case is a 74-year-old female patient who underwent a laparoscopic anterior radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic body cancer. In operative finding, portal confluence (superior mesenteric vein-splenic vein-portal vein) was encased with the uncinate process of pancreas in both cases. Therefore, they required pancreatic division at the pancreatic neck portion twice. During the postoperative period, grade B and A, respectively, postoperative pancreatic fistulas occurred and were controlled by conservative management. Surgeons need to know about this rare pancreatic condition prior to surgical intervention to avoid complications, and to provide patients with well-designed, case-specific pancreatic surgery.

Gastric Duplication Cyst with Ectopic Pancreas in a Child / 대한소화기학회지

No abstract available.

Pancreatic Islet Cell Amyloidosis Manifesting as a Large Pancreas

A 39-year-old female patient presented to our hospital with epigastric pain lasting for two months. Laboratory results showed impaired glucose tolerance. Ultrasonography of the patient showed a hypoechoic, diffusely enlarged pancreas. CT revealed a large pancreas, with multiple calcifications. On MRI, a diffusely enlarged pancreas was seen hypointense on both T1- and T2-weighted images with heterogeneous enhancement after gadolinium administration. A biopsy of the pancreas revealed primary amyloidosis of islet cells. Decreased signal on T1-weighted images without inflammation findings on CT and MRI were clues for the diagnosis.

Imaging Findings of Localized Lymphoid Hyperplasia of the Pancreas: a Case Report

We report here on a case of localized lymphoid hyperplasia of the pancreas in a 70-year-old man which manifested as double lesions (uncinate process and tail) in the organ. The lesions were incidentally detected as hypoechoic lesions on ultrasonography and they appeared as delayed enhancing lesions on the contrast-enhanced dynamic CT and MRI. Total pancreatectomy was performed, because malignant tumor could not be excluded according to the preoperative imaging studies and the endoscopic ultrasound-guided biopsy failed. Pathology revealed localized lymphoid hyperplasia. The patient had an uneventful postoperative course. He has been alive for 18 months after surgery.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatograpy in Very Elderly Patients / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatograpy (ERCP) is often used for the diagnosis and treatment of pancreaticobiliary diseases in the elderly patients. However, few studies have assessed its efficacy and safety in the very elderly. The purpose of this study was to evaluate the clinical outcomes of ERCP in the very elderly patients. METHODS: Eight hundreds two patients who underwent ERCP at Seoul National University Bundang hospital were enrolled retrospectively. They were divided into three groups according to their ages (non-elderly group, elderly group and very-elderly group; or =80, respectively). The indications and clinical outcomes including the complications of ERCP were compared among groups. RESULTS: The most common indication of ERCP was acute cholangitis in all the three groups. Periampullary diverticulum was more frequently observed in elderly and very-elderly patients than in younger patients. Mean duration of hospitalization was not different among three groups. ERCP success rate in all enrolled patients was approximately 90%, and there was no difference in terms of technical success rate between groups (p=0.1). However, the number of ERCP sessions was significantly higher in the very-elderly patients compared to in the non-elderly and elderly (1.38 vs. 1.13 and 1.18 respectively; p<0.001). There was no difference in mortality and complication rate between groups. CONCLUSIONS: ERCP can be performed safely in very-elderly patients. Therefore, only age should not be regarded as one of the major determining factors whether to perform ERCP.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatograpy in Very Elderly Patients / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatograpy (ERCP) is often used for the diagnosis and treatment of pancreaticobiliary diseases in the elderly patients. However, few studies have assessed its efficacy and safety in the very elderly. The purpose of this study was to evaluate the clinical outcomes of ERCP in the very elderly patients. METHODS: Eight hundreds two patients who underwent ERCP at Seoul National University Bundang hospital were enrolled retrospectively. They were divided into three groups according to their ages (non-elderly group, elderly group and very-elderly group; or =80, respectively). The indications and clinical outcomes including the complications of ERCP were compared among groups. RESULTS: The most common indication of ERCP was acute cholangitis in all the three groups. Periampullary diverticulum was more frequently observed in elderly and very-elderly patients than in younger patients. Mean duration of hospitalization was not different among three groups. ERCP success rate in all enrolled patients was approximately 90%, and there was no difference in terms of technical success rate between groups (p=0.1). However, the number of ERCP sessions was significantly higher in the very-elderly patients compared to in the non-elderly and elderly (1.38 vs. 1.13 and 1.18 respectively; p<0.001). There was no difference in mortality and complication rate between groups. CONCLUSIONS: ERCP can be performed safely in very-elderly patients. Therefore, only age should not be regarded as one of the major determining factors whether to perform ERCP.